Violence, Sensation Seeking, and lmpulsivity in Schizophrenics Found Unfit to Stand Trial Sean Z. Kaliski, MMed, FCPsych(SA) and Tuviah Zabow, DPM, FCPsych(SA) Many studies have confirmed an association between violent behavior, impul- sivity, and sensation seeking in nonpsychotic subjects. Schizophrenic patients (n = 49) who had been found unfit to stand trial were investigated for violence, ac- cording to index offenses and longitudinal histories (before and after admission) for violence. Those charged with violent offenses were significantly more often married with children, and were equally likely to direct their assaultiveness to strangers, acquaintances, and family members. The nature of the index offense seemed to be a good indicator of general violent propensity. No significant differ- ences were found on Barratt's lmpulsivity Scale and Zuckerman's Sensation Seeking Scale, except that schizophrenic patients with negative histories of vio- lence scored higher on the thrill and adventure subscale. No pattern of substance abuse differentiated the groups. Patients charged with violent offenses more often presented with persecutory delusions, but this did not extend to those whose histories were positive for repetitive violence. Although impulsivity and sensation seeking do not seem to cause violent behavior in this group, psy- chopathology can also only be regarded as a necessary but not sufficient deter- minant. Most schizophrenics are not violent. Yet gests that a small number of schizo- community, hospital, and prison surveys phrenic patients are disproportionately vi- have indicated a slight preponderance of olent. Characteristics that would clearly patients with schizophrenia among sam- delineate this group from the general ples of violent individuals.'-"his sug- schizophrenic population continue to be elusive. Findings on the determinants of Dr. Kaliski is consultant psychiatrist, Forensic Unit, violence in schizophrenic patients have Valkenberg Hospital, and lecturer, Department of Psy- not been generally consistent. Factors chiatry, University of Cape Town; and Dr. Zabow is as- sociate professor of psychiatry, University of Cape consequent to or irrelevant to the illness, Town, South Africa. This research was supported by a or specific manifestations of the psy- grant from the Human Sciences Research Council. Ad- dress correspondence to: Sean 2. Kaliski, MMed, De- chosis itself, have been variously impli- partment of Psychiatry, University of Cape Town, ~ated."~Most studies have compared Groote Schuur Hospital, Observatory 7925, Cape Town, South Africa. schizophrenic patients with other diag- Bull Am Acad Psychiatry Law, Vol. 23, No. 1, 1995 147 Kaliski and Zabow nostic categories or control subjects, or atric hospital to determine ability to stand have merely listed the attributes of violent trial and criminal responsibility (by rea- patients referred for treatment. Few have son of mental illness). If defendants fail attempted to compare violent and nonvio- these tests, the courts are obliged to cer- lent schizophrenic patients. Antisocial tify and admit them to a forensic unit for schizophrenic patients are a potentially an indefinite period for treatment, regard- useful group for such a comparison, be- less of the nature of the original charge. cause, although many have flouted the The Forensic Unit at Valkenberg Hospital law, some are never violent, others are ha- (and the Department of Psychiatry at the bitually so, and many have displayed only University of Cape Town, South Africa) an occasional or single outburst of vio- provides such a service for the Cape lence. Province, which has a population of about Impulsivity and sensation seeking have 10 million.16 been associated with violent behavior in nonpsychotic individuals, presumably by being linked to a relatively decreased sero- Method tonergic neurotransmission.9-'3 Whether All subjects were in patients in the these dimensions apply to schizophrenic forensic psychiatry unit at Valkenberg patients as well has not been addressed Psychiatric Hospital. They had been certi- adequately, although a recent study14 has fied and hospitalized after a 30-day obser- suggested that low cerebrospinal fluid 5- vation in the unit, which had been ordered hydroxy-indoleacetetate (HIAA) concen- by a court (following a criminal charge). trations predict suicide attempts (suppos- Informed consent was obtained from each edly indicative of impulsivity), but not subject. violent behavior, in these patients. Yet vi- The inclusion criteria were a diagnosis olent outbursts by schizophrenic patients of schizophrenia (according to DSM-III- often seem to be impulsive and reckless, R criteria), fluency in English or Afri- and not simply a consequence of their kaans, sufficient collateral information psychopathology. available about behavior exhibited before The aim of this study was to compare the current admission, and a stable clini- violent and nonviolent antisocial schizo- cal condition as evidenced by no medica- phrenic patients according to variables tion changes during the previous month. that relate directly to the disorder, as well The exclusion criteria were a history of as those that have been shown previously an organic brain syndrome (or any med- to be associated with violence such as im- ical or neurological condition that possi- pulsivity, sensation seeking, past convic- bly could contribute to an altered mental tions, and alcohol and substance abuse.4' l5 state), an inability to communicate, other In South Africa the Criminal Procedure concurrent major psychiatric disorders Act (No. 51, 1977) provides for the refer- (on Axis I) excluding alcohol and sub- ral of a defendant at any stage of proceed- stance abuse disorders, and female sex ings for 30 days' observation at a psychi- (too few women had been admitted to the 148 Bull Am Acad Psychiatry Law, Vol. 23, No. 1, 1995 Schizophrenics Found Unfit to Stand Trial unit, which precluded meaningful com- together as a 'white pipe') are almost ex- parisons). clusively abused. Initially 55 subjects were identified for 6. The positive psychotic symptoms entry; however, three withdrew consent elicited during the initial 30-day observa- during testing, two did not appear to un- tion period by the multidisciplinary team derstand the questions during testing, and were listed. one absconded from the hospital before A true-false version of Barratt's Impul- testing was completed. Therefore, 49 pa- sivity Scale (BIS), which yields a possible tients completed the study. maximum score of 44 points, was used.I7 The following data were recorded: This version was chosen to enhance com- 1. Demographics: age, marital status, pliance. Zuckerman's Sensation Seeking number of children, occupation before ad- Scale (SSS)" was administered. The SSS mission, urban or rural background, edu- consists of the thrill and adventure, experi- cational level. ence seeking, disinhibition, and boredom 2. The alleged offense that resulted in susceptibility subscales, each with a possi- the admission and the relationship of the ble maximum of 10 points (that is, yield- victim to the offender (index offense). ing a maximum of 40 points overall on the Collateral evidence of violent behavior SSS). The reliability and validity of both was obtained from social reports coni- scales have been previously d~cumented.~' piled during the initial observation period '' Although both are usually administered and from ward notes made during the sub- as self-report questionnaires, a psychiatric sequent hospitalization. A history of at nurse was posted nearby to enable the sub- least one previous conviction for a violent ject to clarify items and as a means of as- offense, a social report that described a sessing the subject's motivation and un- pattern of violent behavior or more than derstanding of the questionnaires. two reports of assaultive behavior during The questionnaires were translated into the present admission constituted a posi- Afrikaans by a translator who has training tive history of violence. The index offense in the social sciences in the Human was excluded from this consideration. Sciences Research Council. Occasional 3. Psychiatric history, including the du- phrases and words were translated into ration of disorder (from when first diag- the local idiom. nosed to date of admission), number of Statistical analysis was effected by the previous admissions, the duration of the chi-square test for analysis of categorical present admission, and the presence of a data. (Fisher's Exact Test was employed family history of psychiatric disorder. when expected cell numbers were less 4. Past criminal convictions, which than five, and continuous data were ana- were obtained from the Department of lyzed by Student's t test.) A significance Justice. value of p = .05 (one-tailed) was used. 5. Alcohol and substance abuse. In the The Ethics Committee of the University Cape Province, South Africa, alcohol, can- of Cape Town Medical School approved nabis, and methaqualone-cannabis (smoked the study. Bull Am Acad Psychiatry Law, Vol. 23, No. 1, 1995 149 Kaliski and Zabow Results Table 2 lndex Offense Compared to The average age of the sample was History of Violence 31.49 years (SD = ?8.14, range = 19 to History History 53 years). On average, each patient had Positive Negative Total 1.04 children, although 27 had none and Violent offense 17 5 22 one subject had eight children. Most were Nonviolent offense 7 20 27 from urban areas (n = 31), single (n = Total 24 25 49 34), and